Self-Identification Survey

About this survey: Being a family caregiver has its ups and downs. Use this survey to learn more about how you're doing. Sometimes you are so focused on helping your loved one that you forget to monitor HOW ARE YOU DOING?

This survey will help you learn more about your stress and will provide some suggestions for services.

Instructions:

Answer Yes or No to the following questions by clicking the radio button next to each statement. Click the Calculate Score button when you finish and then read the survey key (located below this survey) to determine your level of distress.

Yes

No

During the past week or so, I have:

1. Had trouble keeping my mind on what I was doing.

2. Felt that I couldn't leave my relative/care recipient alone.

3. Had difficulty making decisions.

4. Felt completely overwhelmed.

5. Felt useful and needed.

6. Felt lonely.

7. Been upset that my relative/care recipient has changed so much from his/her former self.

8. Felt a loss of privacy and/or personal time.

9. Been edgy or irritable.

10. Had sleep disturbed because of caring for my relative/care recipient.

11. Had a crying spell(s).

12. Felt strained between work and family responsibilities.

13. Had back pain.

14. Felt ill (headaches, stomach problems, or common cold).

15. Been satisfied with the support my family has given me.

16. Found my relative's/care recipient's living situation to be inconvenient or a barrier to care.

17.
On a scale of 1 to 10, with 1 being "not stressful"
and 10 being "extremely stressful," please rate
your current level of stress.

18.
On a scale of 1 to 10, with 1 being "very healthy"
and 10 being "very ill," please rate your current
health compared to what it was this time last year.

Your Score:

Error Message: Because your browser is
not JavaScript enabled, the score cannot be calculated. You must
enable JavaScript in your browser to use this survey.

If
Your Score Is:

It
Means...

9 or less

Chances are, you have a low degree of distress.

10 or more

Chances are, you have a high degree of distress.

Note:

If you answered "Yes" to either or both Questions 4 and 11, you have a high degree of distress.

If your score on Question 17 or 18 is 6 or higher, you have a high degree of distress.

If your score indicates a high degree of distress, we recommend that you consider professional assistance. Click the link below for more information: